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1841280716

NPI Code Detail

MEDICARE: DR. CORNELIA SELMA DE RIESE MD, PHD, MBA

MEDICARE: DR. CORNELIA SELMA DE RIESE MD, PHD, MBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	L6348	TX
2	207VF0040X	Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician	L6348	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	111572101	OTHER	TX	FIRSTCARE COMMERCIAL
3	A117	OTHER	NM	TRIWEST
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	83G037	OTHER	TX	BC/BS
9	84497	OTHER	NM	PRESBYTERIAN COMMERCIAL
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	80833Z	OTHER	TX	HMO BLUE

General Provider Information

NPI Number	:	1841280716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CORNELIA SELMA DE RIESE MD, PHD, MBA

Provider Business Mailing Address
First Line	:	701 W 5TH ST # 3212
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79763-4206
Country	:	US
Telephone Number	:	432-703-5000
Fax Number	:	432-335-5240

Provider Business Practice Location Address
First Line	:	701 W 5TH ST
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79763-4206
Country	:	US
Telephone Number	:	432-335-2222
Fax Number	:	432-335-1009

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	04/30/2021

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Directions to “ DR. CORNELIA SELMA DE RIESE MD, PHD, MBA” Practice Location

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